Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
ACUTE CHOLECYSTITIS- RUQ ABDOMINAL PAIN
#surgicaleducator #ruqabdominalpain #acutecholecystitis #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Acute Cholecystitis
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for RUQ pain, etiology, pathology, clinical features, investigations, complications and treatment of Acute Cholecystitis.
• I have also included a mind map, a diagnostic and a treatment algorithm for Acute Appendicitis.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following links:
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
ACUTE CHOLECYSTITIS- RUQ ABDOMINAL PAIN
#surgicaleducator #ruqabdominalpain #acutecholecystitis #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Acute Cholecystitis
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for RUQ pain, etiology, pathology, clinical features, investigations, complications and treatment of Acute Cholecystitis.
• I have also included a mind map, a diagnostic and a treatment algorithm for Acute Appendicitis.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following links:
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
"48 SLIDES???!!", my friends shouted.
A boring "48 slides" is depend on how you arrange it. And this is not the one for sure.
I always love to prepare a short and sweet presentation. Or maybe long but sweet presentation? Oh yeah! Enjoy!
#SLIDESKILLSvsSLIDEKILLS
A quick review of the various benign pathologic conditions of Gallbladder,intended primarily for the Undergraduate students; Based on Bailey & Love's Short Practise of Surgery latest edition.
This PPT contains all necessary detail about cholecystitis and its management and covers all aspects of this disease according to nursing point of view. Helpful for studetns.
The lecture overviews the different situations where cholecystitis can be fatal,if not accurately diagnosed.Different types of dangerous cholecystitis are illustrated with their imaging findings.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
2. Normally, the liver secretes
approximately 500 ml of
bile per day and the
gallbladder concentrates it
5-10 times.
The motility, concentration
and relaxation of the
gallbladder are under the
influence of a peptide
hormone, cholecystokinin
(CCK), released from
neuroendocrine cells of the
duodenum and jejunum.
Cholesterol,
Bile Pigments,
Calcium Salts
CHOL, GALL Liver secretes 400-800 ml bile per day
Lecithin
3. Gall bladder Collects, Stores & Concentrates Bile
The commonest location of impaction of a
gallstone is Hartmann’s pouch?
Hartmann's pouch is an out-pouching of the
wall of the gallbladder at the junction of the
neck of the gallbladder and the cystic duct.
Common hepatic
duct
Rt
hepatic
duct
Lt h duct
Obstruction of
the Cystic duct
4. • Cholecystitis (Greek, -cholecyst, "gallbladder",
combined with the suffix -itis, "inflammation") is
inflammation of the gallbladder, which
occurs most commonly due to
obstruction of the cystic duct with
gallstones (cholelithiasis).
Gall bladder- Cholecyst, Biliary Vesicle, Bile Bladder
5. Classification of Cholecystitis
I. Acute Cholecystitis: calculous & acalculous
II. Chronic Cholecystitis
III. Acute superimposed on chronic
6.
7. Acute Calculous Cholecystitis (90%)
• Acute Calculous cholecystitis is an acute
inflammation of the gallbladder, precipitated 90%
of the time by obstruction of the neck or cystic
duct (by gallstones).
It is the primary complication of gallstones and
the most common reason for emergency
cholecystectomy.
Obstruction→Distension→Inflammation
(due to chemical irritation & Infection)
Hartmann's pouch is an out-pouching of the wall of the gallbladder at the junction
of the neck of the gallbladder and the cystic duct.
The commonest location of impaction of a gallstone is Hartmann’s pouch.
8. Acalculous cholecystitis (10%)
• Cholecystitis without gallstones,
called acalculous cholecystitis may occur in
severely ill patients and accounts for about 10% of
patients with cholecystitis.
9. Pathogenesis- Calculous cholecystitis
• Acute CALCULOUS cholecystitis results from
chemical irritation and inflammation of the
obstructed gallbladder.
• The action of mucosal phospholipases hydrolyzes
luminal lecithins (Phospholipids) to toxic
LYSOLECITHINS.
• The normally protective glycoprotein mucus layer
is disrupted, exposing the mucosal epithelium to
the direct DETERGENT action of bile salts.
10. • Prostaglandins released within the wall of the
distended gallbladder contribute to mucosal and
mural inflammation.
• Gallbladder dysmotility develops; distention and
increased intraluminal pressure compromise blood
flow to the mucosa.
• Acute calculous cholecystitis frequently develops
in diabeticpatients who have symptomatic
gallstones.
DIABETICS
22. Pathogenesis- Acalculous cholecystitis
• Acute ACALCULOUS cholecystitis is thought to
result from ISCHEMIA.
The cystic artery is an end artery with essentially
no collateral circulation.
24. ***Risk factors for acute Acalculous
cholecystitis include:
(1) Sepsis with hypotension and multisystem
organ failure;
(2) Immunosuppression;
(3) Major trauma and burns;
(4) Diabetes mellitus; &
(5) Infections.
(Salmanellosis & Cholera), Parasitic infestation
Major nonbiliary surgery
Dehydration, gallbladder stasis
and sludging, vascular
compromise, and, ultimately,
bacterial contamination.
Sepsis: The presence of pus-forming bacteria or their toxins in blood or tissues.
Recent childbirth, Torsion of GB
Cause
Ischemia
Severely Ill Patients
25. Morphology
GROSS:
Size: The gallbladder is usually enlarged and tense,
Color: bright red or blotchy, violaceous to green-
black discoloration, imparted by subserosal
hemorrhages.
Serosa : The serosal covering is frequently layered by
fibrin and, in severe cases, by a definite
suppurative, coagulated exudate.
Except for the presence or absence of calculi, the two forms of acute cholecystitis are
morphologically similar.
26.
27.
28.
29. Morphology
Gross: On cut section:
• Neck & Cystic duct: an obstructing stone is usually
present
• LUMEN: Stones + Bile (cloudy or turbid bile that may contain large
amounts of fibrin, pus, & hemorrhage).
• WALL: Thickened, edematous, and hyperemic.
30. • In more severe cases GB is transformed into a
green-black necrotic organ, termed Gangrenous
cholecystitis, with small-to-large perforations.
• The invasion of GAS-FORMING ORGANISMS,
notably clostridia and coliforms, may cause an
acute “Emphysematous” cholecystitis.
• Mucosa: Bright Red, swollen.
• When obstruction of the cystic duct is complete,
the lumen is filled with purulent exudate and the
condition is known as EMPYEMA of the
gallbladder.
31.
32. Microscopy
The inflammatory reactions are not distinctive and
consist of the usual patterns of acute
inflammation:
Edema,
Leukocytic infiltration,
Vascular congestion,
Frank abscess formation, or
Gangrenous necrosis.
33.
34. Clinical Features
•PAIN, fever, anorexia, tachycardia,
sweating, nausea, vomiting & mild jaundice.
• The pain may be referred pain that is felt in the
right scapula rather than the right upper quadrant
or epigastric region (Boas' sign). Phrenic Nerve
Boas's sign is hyperaesthesia (increased or altered sensitivity) below the right
scapula .
The patients of acute cholecystitis of either type have similar clinical features.
with features of peritoneal irritation such as guarding and hyperaesthesia.
The gallbladder is tender and may be palpable.
Leucocytosis with
neutrophilia
35. • PAIN may also correlate with eating greasy, fatty,
or fried foods. CCK
• The Murphy sign is specific, but not sensitive for
cholecystitis.
• Elderly patients and those with diabetes may have
vague symptoms that may not include fever or
localized tenderness.
Classically Murphy's sign is tested for during an abdominal examination; it is performed by
asking the patient to breathe out and then gently placing the hand below the costal margin
on the right side at the mid-clavicular line (the approximate location of the gallbladder). The
patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal
contents are pushed downward as the diaphragm moves down (and lungs expand). If the
patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in
contact with the examiner's fingers) and winces with a 'catch' in breath, the test is
considered positive. In order for the test to be considered positive, the same maneuver must
not elicit pain when performed on the left side. Ultrasound imaging can be used to ensure
the hand is properly positioned over the gallbladder
36. Clinical features
• More severe symptoms such as high fever, shock
and jaundice indicate the development of
complications such as
•Abscess formation,
•Perforation or
•Ascending cholangitis.
37. • Another complication, gallstone ileus,
occurs if the gallbladder perforates and forms a
fistula with the nearby small bowel, leading to
symptoms of intestinal obstruction.
Ileus is a disruption of the normal
propulsive ability of the gastrointestinal tract
. It is caused by failure of peristalsis i.e.
non-mechanical obstruction.
38. • Clinical symptoms of acute acalculous cholecystitis
tend to be more insidious, since symptoms are
obscured by the underlying conditions
precipitating the attacks.
• As a result of either delay in diagnosis or the
disease itself, the incidence of gangrene and
perforation is much higher in acalculous
than in calculous cholecystitis.
Early cholecystectomy within the first three days has a mortality of less than
0.5% and risk of complications such as perforation, biliary fistula, recurrent
attacks and adhesions is avoided. However, medical treatment brings about
resolution in a fairly large proportion of cases though chances of recurrence of
attack persist.
39.
40. Chronic cholecystitis is the commonest type of clinical gallbladder disease. There
is almost constant association of chronic cholecystitis with cholelithiasis.
41. Chronic Cholecystitis
• Chronic cholecystitis may be a sequel to repeated
bouts of mild to severe acute cholecystitis,
• but in many instances it develops in the apparent
absence of ANTECEDENT attacks.
• Since it is associated with CHOLELITHIASIS in more
than 90% of cases, the patient
populations are the same as those for gallstones.
90-95%
42. • Supersaturation of bile predisposes to
both chronic inflammation and, in most
instances, stone formation.
• Unlike acute calculous cholecystitis, obstruction of
gallbladder outflow is NOT a requisite.
• The symptoms of calculous chronic cholecystitis
are biliary colic to indolent right upper quadrant
pain & epigastric distress.
48. Morphology
• The morphologic changes in chronic cholecystitis
are extremely variable & sometimes minimal.
The serosa is usually smooth and glistening but
may be dulled by subserosal fibrosis.
• Dense fibrous adhesions
• On sectioning, the WALL is variably thickened,
and has an opaque gray-white APPEARANCE.
Serosa, Wall, Appearance, Lumen & Mucosa.
49. • In the uncomplicated case
• The LUMEN contains fairly clear, green-
yellow, mucoid BILEand usually STONES.
• The MUCOSAitself is generally preserved?.
50. Microscopy- Chronic cholecystitis
• In the mildest cases, only scattered
LYMPHOCYTES, PLASMA CELLS, & MACROPHAGES
are found in the mucosa and in the subserosal fibrous
tissue.
• In more advanced cases there is marked
subepithelial and subserosal FIBROSIS,
accompanied by MONONUCLEAR CELL
INFILTRATION.
CHRONIC INFLAMMATION
51. • Outpouchings of the mucosal epithelium through
the wall
(Rokitansky-Aschoff sinuses) may
be quite prominent.
Rokitansky–Aschoff sinuses, also
entrapped epithelial crypts, are
pseudodiverticula or pockets in the wall of
the gallbladder.Histologically they are outpouchings of gallbladder mucosa into the gallbladder
muscle layer and subserosal tissue.
They are not of themselves considered abnormal,
but they can be associated with cholecystitis.
They form as a result of increased pressure in the gallbladder and recurrent
damage to the wall of the gallbladder. They are associated with gallstones
(cholelithiasis).
Carl Freiherr von Rokitansky and Ludwig Aschoff
Germans.
52. Outpouchings of gallbladder mucosa into the gallbladder muscle layer and
subserosal tissue
Rokitansky-Aschoff
sinuses
Entrapped epithelial
crypts
Ppseudodiverticula
Pockets in the wall of the gallbladder
57. Microscopy- HM
• 1. Thickened and congested mucosa but
occasionally mucosa may be totally destroyed.
• 2. Penetration of the mucosa deep into the wall of
the gallbladder up to muscularis layer to form
Rokitansky- Aschoff’sinuses.
• 3. Variable degree of chronic inflammatory
reaction, consisting of lymphocytes, plasma cells
and macrophages, present in the lamina propria
and subserosal layer.
• 4. Variable degree of fibrosis in the subserosal and
subepithelial layers.
58. A few morphologic variants of chronic cholecystitis are considered below:
Cholecystitis glandularis,
Porcelain gallbladder,
Acute on chronic cholecystitis.
• Cholecystitis glandularis:
when the mucosal folds fuse together due to
inflammation and result in formation of crypts of
epithelium buried in the gallbladder wall.
59. Acute superimposed on
chronic cholecystitis
Superimposition of acute
inflammatory changes implies acute
exacerbation of an already chronically
injured gallbladder.
60. Porcelain gallbladder
• In rare instances extensive dystrophic
calcification
within the gallbladder wall may yield a porcelain
gallbladder, notable for a markedly increased
incidence of associated CANCER.
Chinaware, Pottery, ceramic
Porcelain GB: When the gallbladder wall is calcified and cracks like an egg-shell.
Dystrophic Calcification
62. Clinical Features
Chronic cholecystitis has ill-defined and vague
symptoms. Generally, the patient presents with
abdominal distension or epigastric discomfort,
especially after a fatty meal. There is a constant
dullache in the right hypochondrium and
epigastrium and tenderness over the right upper
abdomen. Nausea and flatulence are common.
Biliary colic may occasionally occur due to passage
of stone into the bile ducts.
63. Xanthogranulomatous cholecystitis
• is also a rare condition in which the gallbladder
has a massively thickened wall, is
shrunken, nodular, and chronically inflamed with
foci of necrosis and hemorrhage.
Strawberrygallbladder, more formally cholesterolosis of the
gallbladder, is a change in the gallbladder wall due to excess cholesterol
CHOLESTEROLOSIS
64.
65. Hydropsof the gallbladder
• Finally, an atrophic, chronically
obstructed gallbladder may
contain only clear secretions, a condition
known as hydrops of the gallbladder.
.
Hydrops is the excessive accumulation of
serous fluid in tissues or cavities of the body.